Accepted Manuscript First case of Nocardia amamiensis pulmonary infection in Mexico Areli Martinez-Gamboa, Miguel E Cervera-Hernandez, Pedro Torres-Gonzalez, Andrea Rangel-Cordero, Alfredo Ponce-de-Leon, Jose Sifuentes-Osornio PII: S2052-2975(16)30141-X DOI: 10.1016/j.nmni.2016.12.005 Reference: NMNI 272 To appear in: New Microbes and New Infections Received Date: May 2016 Revised Date: 24 November 2016 Accepted Date: December 2016 Please cite this article as: Martinez-Gamboa A, Cervera-Hernandez ME, Torres-Gonzalez P, RangelCordero A, Ponce-de-Leon A, Sifuentes-Osornio J, First case of Nocardia amamiensis pulmonary infection in Mexico, New Microbes and New Infections (2017), doi: 10.1016/j.nmni.2016.12.005 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain ACCEPTED MANUSCRIPT Category: First Clinical Case Report Title: First case of Nocardia amamiensis pulmonary infection in Mexico RI PT Running title: Nocardia amamiensis pulmonary infection Authors and affiliations: a a a Areli Martinez-Gamboa , Miguel E Cervera-Hernandez , Pedro Torres-Gonzalez , Andrea Rangela a b SC Cordero , Alfredo Ponce-de-Leon , Jose Sifuentes-Osornio a Department of Infectious Diseases, Laboratory of Clinical Microbiology, Instituto Nacional de M AN U Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico b Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico Corresponding author: Jose Sifuentes-Osornio e-mail: sifuentesosornio@gmail.com Phone and Fax: +52 55 5487 0900 Address: Vasco de Quiroga 15, Colonia Belisario Dominguez Seccion XVI, AC C EP TE D Tlalpan 14080, Mexico City, Mexico ACCEPTED MANUSCRIPT Category: First Clinical Case Report Title: First case of Nocardia amamiensis pulmonary infection in Mexico Running title: Nocardia amamiensis pulmonary infection Abstract We report a case of Nocardia amamiensis pulmonary infection in a 43-year-old immunocompromised woman The patient was treated with imipenem/cilastatin and trimethoprim/sulfamethoxazole and had a favourable outcome It is important that laboratories perform species identification to understand the epidemiology and susceptibility patterns of the different Nocardia spp M AN U SC RI PT Keywords 11 Nocardia amamiensis; pulmonary nocardiosis; immunocompromised, antimicrobial 12 susceptibility EP AC C 13 TE D 10 ACCEPTED MANUSCRIPT In 2007, a novel species, Nocardia amamiensis, was identified from the soil in a cane- 15 sugar field in Japan [1] To date, there have been reported cases (ocular=2, 16 pulmonary=1) of N amamiensis infection [2, 3] Here we report a pulmonary infection in an 17 immunocompromised patient 18 In 2014, a 43-year-old woman from Oaxaca, Mexico; presented to the emergency room 19 with recent onset shortness of breath; she referred fever, weight loss, and productive 20 cough over the last three months Her medical history included primary glomerulonephritis 21 treated with 32.5 mg/day of prednisone and tacrolimus for the previous five months During 22 the initial evaluation, she had diminished breath sounds over the right lung base and 23 tachycardia A contrast-enhanced computed tomography of the chest revealed multiple 24 cavitary lesions in the right lower lung lobe Laboratory studies revealed hemoglobin of 8.2 25 g/dL, and 13,800/µL white blood cells Empiric treatment with intravenous clindamycin and 26 ceftriaxone was initiated We performed a bronchoalveolar lavage, and the sample was 27 inoculated in sheep blood agar at 5% plates and incubated under aerobic conditions at 35 28 °C After six days of incubation, we observed the g rowth of chalky irregular gray colonies 29 in the culture media which were positive to the modified Kinyoun acid-fast staining We 30 performed conventional biochemical tests (Table 1) along with amplification and nucleotide 31 sequencing of the partial 16S rRNA, and secA1 genes, the sequences were compared 32 with the available at the National Centre for Biotechnology Information Database 33 (http://www.ncbi.nlm.nih.gov), the interpretation was performed according to the statement 34 by CLSI [4] The nucleotide sequences showed 100% and 99.6% de match with the N 35 amamiensis respectively Also, we performed susceptibility testing for 36 amoxicillin/clavulanate, moxifloxacin, imipenem and amikacin according to the statement 37 by the CLSI [5] (Table 1) AC C EP TE D M AN U SC RI PT 14 ACCEPTED MANUSCRIPT On day nine of admission, the patient developed acute respiratory distress syndrome that 39 required mechanical ventilatory support She was transferred to the intensive care unit 40 (ICU) where she spent one month with a fluctuating clinical course Upon Nocardia spp 41 identification, ceftriaxone, and clindamycin were discontinued, and she was started on 42 imipenem/cilastatin and trimethoprim/sulfamethoxazole Brain, magnetic resonance 43 imaging, was negative for central nervous system dissemination, and prednisone was 44 tapered down over the course of hospitalization After weaning from mechanical 45 ventilation, she was discharged from the ICU and completed 36 days of 46 imipenem/cilastatin and trimethoprim/sulfamethoxazole The patient was discharged from 47 the hospital and sent home with trimethoprim/sulfamethoxazole prophylaxis No relapse 48 episodes have been documented after 20 months of follow-up 49 Nocardia spp are branching, gram-positive rods that occasionally cause infection in 50 humans Over two-thirds of the patients have depressed cell-mediated immunity [6, 7] 51 Nocardia sp are found in the environment, and inhalation is the primary route of 52 contagion Hence, pulmonary nocardiosis is the most frequent clinical presentation [8] The 53 central nervous system is the preferred extrapulmonary site of dissemination, and imaging 54 should be obtained in immunocompromised patients [5] 55 The genus Nocardia comprises more than 86 species and will continue to expand thanks 56 to DNA sequencing Each species may display different antibiotic susceptibility patterns 57 and, levels of pathogenicity [9] Species-level identification is not always possible by 58 biochemical tests, and gene sequencing may help define the proper treatment 59 N amamiensis is a newly recognized cause of pulmonary infection The clinical features 60 resemble those of the rest of the Nocardia genus However, to understand the 61 epidemiology and susceptibility patterns of the different species of Nocardia, it is important 62 for laboratories to identify them using DNA target sequencing promptly AC C EP TE D M AN U SC RI PT 38 ACCEPTED MANUSCRIPT Acknowledgments 64 Written informed consent was obtained from the patient for publication of this case report 65 All authors declare no conflicts of interest This work was funded with internal resources AC C EP TE D M AN U SC RI PT 63 ACCEPTED MANUSCRIPT TE D M AN U SC RI PT Yamamura H, Tamura T, Sakiyama Y, Harayama S Nocardia amamiensis sp nov., isolated from a sugar-cane field in Japan Int J Syst Evol Microbiol 2007; 57(Pt 7): 1599-602 Reddy AK, Garg P, Kaur I Spectrum and clinicomicrobiological profile of Nocardia keratitis caused by rare species of Nocardia identified by 16S rRNA gene sequencing Eye (Lond) 2010; 24(7): 1259-62 Rudramurthy SM, Honnavar P, Kaur H, Samanta P, Ray P, Ghosh A et al Molecular identification of clinical Nocardia isolates from India J Med Microbiol 2015 Petti CA, Clinical and Laboratory Standards Institute Interpretive criteria for identification of bacteria and fungi by DNA target sequencing : approved guideline Wayne, PA: Clinical and Laboratory Standards Institute, 2008 Clinical and Laboratory Standards Institute Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes; Approved Standard-Second Edition CLSI document M24-A2 Wayne; PA: Clinical and Laboratory Standards Insititute;2011 Wilson JW Nocardiosis: updates and clinical overview Mayo Clin Proc 2012; 87(4): 403-7 Marquez-Diaz F, Soto-Ramirez LE, Sifuentes-Osornio J Nocardiasis in patients with HIV infection AIDS Patient Care STDS.1998; 12(11): 825-32 Beaman BL, Beaman L Nocardia species: host-parasite relationships Clin Microbiol Rev 1994; 7(2): 213-64 McTaggart LR, Richardson SE, Witkowska M, Zhang SX Phylogeny and identification of Nocardia species on the basis of multilocus sequence analysis J Clin Microbiol 2010; 48(12): 4525-33 EP 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 References AC C 66 ACCEPTED MANUSCRIPT Table Microbiologic Investigations and Antimicrobial Susceptibility Pattern Biochemical test Result Antimicrobial MIC (mg/L) Urease + TMP / SMX 0.062 / 1.1875 Amoxicillin / clavulanate 4/2 Hydrolysis of: Moxifloxacin >8 - Imipenem 0.5 Xanthine - Amikacin 0.25 RI PT - Tyrosine Hypoxanthine - Esculin - Gene % Similarity Utilization of citrate - 16S rRNA 100 Nitrate reduction + secA1 99.6 Growth at 45 °C - Growth with lysozyme + EP TE D M AN U Abbreviations: MIC, minimum inhibitory concentrations; TMP/SMX, trimethoprim/sulfamethoxazole AC C 93 Casein SC 92 ... MANUSCRIPT Category: First Clinical Case Report Title: First case of Nocardia amamiensis pulmonary infection in Mexico RI PT Running title: Nocardia amamiensis pulmonary infection Authors and... 14080, Mexico City, Mexico ACCEPTED MANUSCRIPT Category: First Clinical Case Report Title: First case of Nocardia amamiensis pulmonary infection in Mexico Running title: Nocardia amamiensis pulmonary. .. amamiensis pulmonary infection Abstract We report a case of Nocardia amamiensis pulmonary infection in a 43-year-old immunocompromised woman The patient was treated with imipenem/cilastatin and trimethoprim/sulfamethoxazole